<!--<?php
print <<<EOT
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<td valign="top">
<table width="100%"  border="0" cellspacing="10" cellpadding="0">
<tr>
<td align="left" valign="top"><form action="" method="post" name="form2" onSubmit="return checkRegForm(this);">
  <input type="hidden" name="act" value="register">
<table width="100%"  border="0" cellspacing="0" cellpadding="0">
  <tr>
    <td height="30" valign="top"><span class="ytitle">Create an account at Acuity World Webshop</span></td>
  </tr>
  <tr>
    <td align="left" valign="top"><table width="426"  border="0" cellpadding="0" cellspacing="2">
        <tr>
          <td height="35" colspan="2" ><strong>Email Address and Password</strong></td>
        </tr>
        <tr>
          <td width="160" >Your email address* :</td>
          <td width="253" ><input name="email" type="text" id="email" style="width:195px"></td>
        </tr>
        <tr>
          <td >Choose your password* :</td>
          <td ><input name="password" type="password" id="password" style="width:195px"></td>
        </tr>
        <tr>
          <td >Type your password again* :</td>
          <td ><input name="verify" type="password" id="verify" style="width:195px"></td>
        </tr>
        <tr>
          <td height="50" colspan="2" >You must use this email address and this password when you log in to <br>
            Acuity World Webshop.</td>
          </tr>
      </table>
      <table width="100%" height="80"  border="0" cellpadding="0" cellspacing="0">
        <tr>
          <td><span ><br>
            <strong>Your Personal Information: </strong></span><br>
          </td>
        </tr>
      </table>
      <table  border="0" cellspacing="2" cellpadding="0">
        <tr>
          <td width="120" >Company* :</td>
          <td><input name="company" type="text" id="company" style="width:195px"></td>
        </tr>
        <tr>
          <td >First Name* :</td>
          <td><input name="firstname" type="text" id="firstname" style="width:195px"></td>
        </tr>
        <tr>
          <td >Last Name* :</td>
          <td><input name="lastname" type="text" id="lastname" style="width:195px"></td>
        </tr>
        <tr>
          <td >Address* :</td>
          <td></td>
        </tr>
        <tr>
          <td ><span style="width:40px;">&nbsp;&nbsp;</span>House no. / Street :</td>
          <td><input name="street" type="text" id="street" style="width:195px"></td>
        </tr>
        <tr>
          <td ><span style="width:40px;">&nbsp;&nbsp;</span>City / Town:</td>
          <td><input name="city" type="text" id="city" style="width:195px"></td>
        </tr>
        <tr id="trProvince">
          <td ><span style="width:40px;">&nbsp;&nbsp;</span>State / Province :</td>
          <td><input name="state" type="text" id="state" style="width:195px"></td>
        </tr>
        <tr>
          <td ><span style="width:40px;">&nbsp;&nbsp;</span>ZIP / Postal Code :</td>
          <td><input name="zip" type="text" id="zip" style="width:195px"></td>
        </tr>
        <tr>
          <td ><span style="width:40px;">&nbsp;&nbsp;</span>Country / Region :</td>
          <td>{$countryStr1}</td>
        </tr>
        <tr>
          <td >Phone* :</td>
          <td><input name="phone1" type="text" id="phone1" style="width:40px" value="+ 45">
            <input name="phone" type="text" id="phone" style="width:149px"></td>
        </tr>
        <tr>
          <td >Mobile :</td>
          <td><input name="mobile1" type="text" id="mobile1" style="width:40px" value="+ 45">
            <input name="mobile" type="text" id="mobile" style="width:149px"></td>
        </tr>
        <tr>
          <td >Fax :</td>
          <td><input name="fax1" type="text" id="fax1" style="width:40px">
            <input name="fax" type="text" id="fax" style="width:149px"></td>
        </tr>
      </table>
      <table width="100%" height="80"  border="0" cellpadding="0" cellspacing="0">
        <tr>
          <td><strong>Delivery Address: </strong>* <br>
            <br>
            The delivery address is the same as above.
            <input type="checkbox" name="check1" id="check1" onclick="copyAddress(form2)"  class="noBorder"/>
          </td>
        </tr>
      </table>
      <table  border="0" cellspacing="2" cellpadding="0">
        <tr>
          <td ><span style="width:40px;">&nbsp;&nbsp;</span>House no. / Street :</td>
          <td><input name="street2" type="text" id="street2" style="width:195px"></td>
        </tr>
        <tr>
          <td ><span style="width:40px;">&nbsp;&nbsp;</span>City / Town:</td>
          <td><input name="city2" type="text" id="city2" style="width:195px"></td>
        </tr>
        <tr id="trProvince2">
          <td ><span style="width:40px;">&nbsp;&nbsp;</span>State / Province :</td>
          <td><input name="state2" type="text" id="state2" style="width:195px"></td>
        </tr>
        <tr>
          <td ><span style="width:40px;">&nbsp;&nbsp;</span>ZIP / Postal Code :</td>
          <td><input name="zip2" type="text" id="zip2" style="width:195px"></td>
        </tr>
        <tr>
          <td ><span style="width:40px;">&nbsp;&nbsp;</span>Country / Region :</td>
          <td>{$countryStr2}</td>
        </tr>
        <tr>
          <td >&nbsp;</td>
          <td >&nbsp;</td>
        </tr>
      </table>
      <table width="100%"  border="0" cellspacing="0" cellpadding="0">
        <tr>
          <td height="20" align="left" valign="top" ><table width="100%"  border="0" cellspacing="2" cellpadding="0">
              <tr>
                <td width="87%" height="20" align="left" valign="top" >Yes, I have read and accepted Acuity World WebShop <a href="delivery_policy.php" target="_blank"><font color="#0000FF"><u>Terms of Sale and Delivery</u></font></a> *</td>
                <td width="13%" align="center" valign="top"><input name="faq1" type="checkbox" class="inputimage" id="q1" value="1"></td>
              </tr>
              <tr>
                <td height="20" align="left" valign="top" >Yes, please send me the Acuity World Newsletter</td>
                <td align="center" valign="top"><input name="faq2" type="checkbox" class="inputimage" id="q2" value="1" checked></td>
              </tr>
              <tr>
                <td height="30" >&nbsp;</td>
                <td>&nbsp;</td>
              </tr>
              <tr>
                <td height="30" align="center" ><input name="submit_join" type="submit" class="inputbt" value="Submit">
                  &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
                  <input name="reset" type="reset" class="inputbt" id="reset" value="Cancel"></td>
                
                <td>&nbsp;</td>
              </tr>
            </table>
        </tr>
      </table></td>
  </tr>
</table>
</form>

</td>
</tr>
</table>
</td>

<!--
EOT;
?>-->